Public Health

Public Health Scotland on meeting the long-term challenges that impact life expectancy

THE PANDEMIC HAS DOMINATED ALL our lives for the last year, with the impact being felt across all aspects of public health.

Even before the emergence of COVID-19, Scotland faced considerable health and wellbeing challenges, including relatively poor life expectancy and the worst health inequalities in western and central Europe.

Public Health Scotland (PHS), the new national organisation for public health, was launched in April 2020 just as the full impact of the pandemic began to hit. For the past year, the COVID response has been integral to its work and will continue to be.

Over the long term, PHS is charged with addressing some of the deepseated challenges which impact on life expectancy and public health more generally.

Angela Leitch, chief executive of Public Health Scotland, explains: “The COVID-19 pandemic has undoubtedly focused the public interest on health and wellbeing and the shared ‘public’ nature of population health.

“Almost a year on since PHS’S launch in the midst of a global public health emergency, addressing the socio-economic determinants of health inequalities remains at the heart of the organisation’s vision of a Scotland where everybody thrives.

“Each of our priorities reflects the areas where the biggest impact can be made. This requires the collective action of our partners across the system, including local and national government, health and social care bodies, and the third sector. We’ve developed a number of key partnerships in our first year of operation in order take forward actions, together, that will make a difference in our communities.” Leitch continues: “We’re a data and intelligence-driven organisation. “This means we use the full range of data – national and local, quantitative and qualitative – to inform action and measure progress.”

Collating and sharing data and intelligence has been central to the organisation’s contribution to the country’s response to COVID-19. Public Health Scotland publishes data on the direct and indirect impacts of the pandemic through weekly statistical reports and daily public-facing dashboards. Where possible, the information is made available at a neighbourhood level, enabling local areas to analyse what it means for them and take the necessary action to prevent and manage outbreaks.

Gerry Mccartney, a consultant in public health at PHS, says: “From the point of view of measuring progress towards our vision of a Scotland where everybody thrives, two indicators are particularly important: life expectancy and health inequalities.

“Life expectancy is an important measure of population health and a good marker of overall societal progress,” Mccartney continues. “Life expectancy in Scotland had been increasing since the 1950s but this increase has now stopped. There has been almost no change in life expectancy in Scotland since 2012. This is the case across all socio-economic groups and almost all age groups, not just the oldest. Life expectancy in our poorest areas has actually decreased. Health inequalities are worsening and socioeconomic factors are increasingly impacting on how long we live for, and how long we live in good health.”

Whilst understanding these complex challenges is an important initial step, so too is understanding what needs done to address them. Public Health Scotland has a role to play in realising both.

The challenge is stark. According to statistics from the National Records of Scotland, healthy life expectancy (the period someone can expect to live in good general health) for both men and women fell between 2017-19. There are also substantial differences across different parts of the country. In Orkney, for example, healthy life expectancy for women is 75.1 years, but the figure falls to just 56.3 years in North Ayrshire – a gap of almost 20 years.

Dr Mccartney argues that it must be acknowledged that the healthy life expectancy figures are worrying.

“What that means is that the experience of life in good health has declined in recent years and that’s been especially the case for women and people in more deprived areas.”

The driver behind the healthy life expectancy figures are the overall life expectancy trends, which have stalled since 2012.

“There’s been virtually no change in life expectancy since 2012 for the population average,” Mccartney says. “But the average hides a lot of detail. For the poorest 40 per cent of the population, the mortality rates have got worse over the last eight years and that’s true for both men and women.”

Improving the length of time people live in good health is a core objective of the Scottish Government’s National Performance Framework, and is a key part of PHS’S mission to work together with partners to improve health and reduce health inequalities. It’s also central to the shared ambition to build back fairer after the pandemic. The national public health organisation is clear that the underlying causes of health inequalities are socio-economic – an unequal distribution of income, power and wealth.

The pandemic has brought an incredible challenge to communities and individuals who were already disadvantaged.

“The pandemic has had a huge impact on many of the determinants of health, and it is not impacting on all our communities equally,” Mccartney says.

“People have lost their jobs, lost income, become more socially isolated. All of those things are damaging to health indirectly, as well as the direct impact to health from the virus.

“If COVID comes under control quite quickly this year with the vaccine, then life expectancy might bounce back to the previous level,” he says. “But it won’t necessarily start improving again unless we get more of the contextual factors in society addressed.”

Ruth Dundas, a senior research fellow in public health at the University of Glasgow who works closely with PHS on the topic of life expectancy and health inequalities, says that while the current pandemic has proved challenging, it has also shown how national and local government, the third sector, other partners and the public can work together when there is a willingness to do so.

“We know (from the pandemic) the value of a multi-agency approach,” she adds. “We need welfare, we need the education policies, the employment policies. These are all needed to tackle the social determinants of ill health.

“We’ve known about health inequalities for over 40 years. It’s not that there’s been nothing going on, but it is frustrating that in that time we haven’t always seen the large-scale population level policies required across all the government departments.”

Leitch adds: “The key is how we work together to take action to improve inequalities.”

PHS’S work to understand both what’s causing the unequal impact of the pandemic and what can be done about it – which Mccartney is leading – is a great example of the benefit of having experts in different fields working together and working with local communities, in a single national body.

“In this case we’re bringing together our outbreak management expertise, with evidence of what works, national data and intelligence from local partners, and evidence of people’s experiences of what really makes a difference to their lives, to support the collective action which will reduce inequality,” says Leitch.

When it comes to large-scale public health interventions, the pandemic has perhaps shown that where there’s a will, there’s a way. But there is no silver bullet when it comes to tackling the significant challenges which Scotland faces.

“If there was a way of ensuring that the impact on health was considered and used as a key decision-making influence in every other policy, that would be really effective,” Mccartney says.

“If in making transport policy, economic policy or employment policy, you had to consider the health impacts and take account of that, it would be the most likely way to generate population health improvements in the future.” To realise the necessary improvements in health and life expectancy, Leitch emphasises that there are many different potential actions across different parts of the system, which Public Health Scotland will work with its partners to take.

“We’re serious about creating a Scotland where everybody thrives, and the work we’ve been doing on planning for the year ahead will ensure we can use the opportunities presented by the recovery period we’re moving into to start to address inequality on a systems wide basis. Collaboration is key, and we will be working alongside partners and stakeholders to take action in the four priority areas in our Strategic Plan.

“We will continue to play a central role in the country’s response to COVID, providing public health expertise, data and intelligence to inform policy and working with partners to support the reopening of sectors and the economy post-lockdown.

“Our work on mental wellbeing will focus on children and young people, mental wellbeing through work, preventing suicide, and supporting the improvement of mental health treatment services. “On poverty and children, we will focus on the labour market, employment and employability, supporting healthy workplaces, shaping economic policy, and developing anchor institutions.

“Our place and communities work will focus on two main areas: supporting and maintaining communities that are inclusive, empowered, resilient and safe, and informing health and social care services to equip them to meet the needs of the communities they serve.

“We have a real opportunity as a country to make a difference to people’s lives, by working together to address the long-lasting issues that pervade many of our communities.” •

“If in making transport policy, economic policy or employment policy, you had to consider the health impacts and take account of that, it would be the most likely way to generate population health improvements in the future”